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Percutaneous Venopulmonary Extracorporeal Membrane Oxygenation as Bridge to Lung Transplantation. ASAIO J 2024:00002480-990000000-00433. [PMID: 38446842 DOI: 10.1097/mat.0000000000002179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Mechanical circulatory support (MCS) as a bridge to lung transplant is an infrequent but accepted pathway in patients who have refractory end-stage pulmonary failure. The American Association of Thoracic Surgeons Expert Consensus Guidelines, published in 2023, recommends venovenous (VV) extracorporeal membrane oxygenation (ECMO) as the initial configuration for those patients who have failed conventional medical therapy, including mechanical ventilation, while waiting for lung transplantation and needing MCS. Alternatively, venoarterial (VA) ECMO can be used in patients with acute right ventricular failure, hemodynamic instability, or refractory respiratory failure. With the advancement in percutaneous venopulmonary (VP) ECMO cannulation techniques, this option is becoming an attractive configuration as bridge to lung transplantation. This configuration enhances stability of the right ventricle, prevents recirculation with direct introduction of pulmonary artery oxygenation, and promotes hemodynamic stability during mobility, rehabilitation, and sedation-weaning trials before lung transplantation. Here, we present a case series of eight percutaneous VP ECMO as bridge to lung transplant with all patients mobilized, awake, and successfully transplanted with survival to hospital discharge.
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Intracannula Thrombus Formation Associated With Dual Lumen ProtekDuo Cannula in Extracorporeal Membrane Oxygenation (ECMO). ASAIO J 2023; 69:e391-e396. [PMID: 36867841 PMCID: PMC10480334 DOI: 10.1097/mat.0000000000001906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is used in cases of severe respiratory failure refractory to medical management. Use of ECMO is increasing, along with new cannulation strategies including oxygenated right ventricular assist devices (oxy-RVADs). Multiple dual lumen cannulas are now available, which increase the potential for patient mobility and decrease the number of vascular access sites. However, dual lumen, single cannula flow can be limited by adequate inflow, requiring the need for an additional inflow cannula to meet patient demands. This cannula configuration may result in differential flows in the inflow and outflow limbs and altered flow dynamics, increasing the risk of intracannula thrombus. We describe a series of four patients treated with oxy-RVAD for COVID-19-associated respiratory failure complicated by dual lumen ProtekDuo intracannula thrombus.
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Oxygenated right ventricular assist device as part of veno-venopulmonary extracorporeal membrane oxygenation to support the right ventricle and pulmonary vasculature. J Cardiothorac Surg 2023; 18:134. [PMID: 37041646 PMCID: PMC10088623 DOI: 10.1186/s13019-023-02264-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/03/2023] [Indexed: 04/13/2023] Open
Abstract
COVID-19 infection can lead to severe acute respiratory distress syndrome (ARDS), right ventricular (RV) failure and pulmonary hypertension. Venovenous extracorporeal membrane oxygenation (V-V ECMO) has been used for patients with refractory hypoxemia. More recently dual-lumen right atrium to pulmonary artery oxygenated right ventricular assist devices (Oxy-RVAD) have been utilized in the severe medical refractory COVID ARDS setting. Historically, animal data has demonstrated that high continuous non-pulsatile RVAD flows, leading to unregulated and unprotected circulation through the pulmonary vessels is associated with an increased risk of pulmonary hemorrhage and increased amount of extravascular lung water. These risks are heightened in the setting of ARDS with fragile capillaries, left ventricular (LV) diastolic failure, COVID cardiomyopathy, and anticoagulation. Concurrently, due to infection, tachycardia, and refractory hypoxemia, high V-V ECMO flows to match high cardiac output are often necessary to maintain systemic oxygenation. Increase in cardiac output without a concurrent increase in VV ECMO flow will result in a higher fraction of deoxygenated blood returning to the right heart and therefore resulting in hypoxemia. Several groups have suggested using a RVAD only strategy in COVID ARDS; however, this exposes the patients to the risk of pulmonary hemorrhage. We present one of the first known cases using an RV mechanical support, partial flow pulmonary circulation, oxygenated Veno-venopulmonary (V-VP) strategy resulting in RV recovery, total renal recovery, awake rehabilitation, and recovery.
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A Case Series of Devastating Intracranial Hemorrhage During Venovenous Extracorporeal Membrane Oxygenation for COVID-19. J Cardiothorac Vasc Anesth 2020; 34:3006-3012. [PMID: 32828653 PMCID: PMC7385062 DOI: 10.1053/j.jvca.2020.07.063] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Anticoagulation may be a challenge in coronavirus disease 2019 (COVID-19) extracorporeal membrane oxygenation due to endothelial injury and dysregulation of coagulation, which may increase the risk of thrombotic and bleeding complications. This report was created to describe the authors' single institutional experience, with emphasis on the high rate of intracranial hemorrhage for the first 10 patients with COVID-19 placed on venovenous extracorporeal membrane oxygenation (VV ECMO). DESIGN Case series, retrospective analysis. SETTING Single institution. PARTICIPANTS Ten patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient characteristics, mortality, stroke rate, and length of stay data were collected in all patients. In addition, laboratory values of D-dimer and C-reactive protein and standard measurements of prothrombin and activated partial thromboplastin time were collected on all patients. Ten patients, each confirmed with COVID-19 via reverse transcription-polymerase chain reaction, were supported on VV ECMO for acute respiratory distress syndrome (ARDS) for a mean duration of 9.4 ± 7 days. Four of 10 patients had hemorrhagic strokes, 3 of which resulted in death. At 30 days after initiation of VV ECMO, a total of 7 survivors included 6 patients discharged from the hospital and 1 patient who remained in the intensive care unit. CONCLUSIONS In this small study of 10 patients, intracranial hemorrhage was a common complication, resulting in a high rate of death. The authors urge caution in the anticoagulation management of VV ECMO for patients with severe ARDS and COVID-19 patients. Close monitoring of all hematologic parameters is recommended during ECMO support while awaiting larger, multicenter studies to examine the best practice.
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Acute Respiratory Failure Managed via Inter-Facility Transport for Extracorporeal Life Support: A 3-Year Experience. J Cardiothorac Vasc Anesth 2018; 33:1865-1870. [PMID: 30559066 DOI: 10.1053/j.jvca.2018.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objectives of this study were as follows: (1) to describe a successful design for a mobile lung rescue program, focusing on challenges and resources required to support such a program, and (2) report short-term outcomes for patients placed on venovenous extracorporeal life support (VV-ECLS) by a transferring team before inter-facility transport to a specialized extracorporeal life support (ECLS) center. DESIGN This retrospective review and analysis used patient chart review to collect outcomes data and resource demand. SETTING A single institutional experience in an academic center in the United States. PARTICIPANTS Patient selection targeted the 75 patients who were placed on VV-ECLS for acute respiratory failure at an outside institution by the authors' team before transport from January 1, 2015, through December 31, 2017. INTERVENTIONS No intervention was made. MEASUREMENTS AND MAIN RESULTS Average time for dispatch and transfer was 4 hours and 10 minutes for ground and 3 hours and 30 minutes for air transport (p = 0.029). Demand was highest in winter, with 61% (46/75) of patients presenting from November through April, and daytime, with 73% (55/75) occurring from 8 am to 8 pm. Demand increased during the study period, with 21 patients in 2015, 24 in 2016, and 30 in 2017. Mortality was low, with 72% of patients surviving to discharge. CONCLUSIONS Herein a successful mobile lung rescue program for transfer to a regional ECLS center is described. These findings demonstrate bed availability during high census and presence of a physician for duration of transport. These challenges can be overcome and successful implementation can be made with low mortality, supporting the development of regional ECLS centers.
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Aortic Valve Prosthesis-Patient Mismatch in a Patient Undergoing Redo Mitral Valve Replacement for Infective Endocarditis. J Cardiothorac Vasc Anesth 2018; 32:2802-2809. [PMID: 29555388 DOI: 10.1053/j.jvca.2018.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Indexed: 11/11/2022]
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In Response. Anesth Analg 2018; 125:706-707. [PMID: 28654432 DOI: 10.1213/ane.0000000000002248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
When clinicians consider extracorporeal life support (ECLS) for acute respiratory distress syndrome (ARDS) patients with hemodynamic instability, both veno-arterial (VA) and veno-venous (VV) ECLS are therapeutic possibilities. We analyzed 17 patients with ARDS on inotropic or vasopressor support requiring ECLS for refractory hypoxemia. After implementing VV ECLS, pressor requirements (based on norepinephrine equivalents) were significantly lower in all patients (P = .0001 for overall comparison across time points). None of the 17 patients required conversion from VV ECLS to VA ECLS (95% confidence interval 0%-20.0%). In this sample of 17 patients with substantial baseline vasopressor support and hypoxemic respiratory failure, initiation of VV ECLS was associated with reduced pressor requirements. Such a strategy may help avoid complications of VA ECLS in patients with both respiratory and hemodynamic failure.
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Cardiac and Critical Care Anesthesiologists May Be Ideal Members of the Mobile ECMO Team. J Cardiothorac Vasc Anesth 2016; 30:1439-1440. [PMID: 27751761 DOI: 10.1053/j.jvca.2016.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Indexed: 11/11/2022]
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Right Coronary Artery Occlusion After Tricuspid Ring Annuloplasty. J Cardiothorac Vasc Anesth 2015; 29:1606-9. [DOI: 10.1053/j.jvca.2014.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Indexed: 11/11/2022]
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Invited Commentary. Ann Thorac Surg 2015; 100:464. [PMID: 26234832 DOI: 10.1016/j.athoracsur.2015.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 11/27/2022]
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The year in cardiothoracic and vascular anesthesia: selected highlights from 2013. J Cardiothorac Vasc Anesth 2014; 28:1-7. [PMID: 24440007 DOI: 10.1053/j.jvca.2013.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Indexed: 12/16/2022]
Abstract
This article reviewed selected research highlights of 2013 that pertain to the specialty of cardiothoracic and vascular anesthesia. The first major theme is the commemoration of the sixtieth anniversary of the first successful cardiac surgical procedure with cardiopulmonary bypass conducted by Dr Gibbon. This major milestone revolutionized the practice of cardiovascular surgery and invigorated a paradigm of mechanical platforms for contemporary perioperative cardiovascular practice. Dr Kolff was also a leading contributor in this area because of his important contributions to the refinement of cardiopulmonary bypass and mechanical ventricular assistance. The second major theme is the diffusion of echocardiography throughout perioperative practice. There are now guidelines and training pathways to guide its generalization into everyday practice. The third major theme is the paradigm shift in perioperative fluid management. Recent large randomized trials suggest that fluids are drugs that require a precise prescription with respect to type, dose, and duration. The final theme is patient safety in the cardiac perioperative environment. A recent expert scientific statement has focused attention on this issue because most perioperative errors are preventable. It is likely that clinical research in this area will blossom because this is a major opportunity for improvement in our specialty. The patient care processes identified in these research highlights will further improve perioperative outcomes for our patients.
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The functional aortic annulus in the 3D era: focus on transcatheter aortic valve replacement for the perioperative echocardiographer. J Cardiothorac Vasc Anesth 2014; 29:240-5. [PMID: 25620147 DOI: 10.1053/j.jvca.2014.05.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Indexed: 02/08/2023]
Abstract
The functional aortic annulus represents a sound clinical framework for understanding the components of the aortic root complex. Recent three-dimensional imaging analysis has demonstrated that the aortic annulus frequently is elliptical rather than circular. Comprehensive three-dimensional quantification of this aortic annular geometry by transesophageal echocardiography and/or multidetector computed tomography is essential to guide precise prosthesis sizing in transcatheter aortic valve replacement to minimize paravalvular leak for optimal clinical outcome. Furthermore, three-dimensional transesophageal echocardiography accurately can quantify additional parameters of the functional aortic annulus such as coronary height for complete sizing profiles for all valve types in transcatheter aortic valve replacement. Although it is maturing rapidly as a clinical imaging modality, its role in transcatheter aortic valve replacement is seen best as complementary to multidetector computed tomography in a multidisciplinary heart team model.
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Incidental tricuspid regurgitation in adult cardiac surgery: focus on current evidence and management options for the perioperative echocardiographer. J Cardiothorac Vasc Anesth 2014; 28:1414-20. [PMID: 25319991 DOI: 10.1053/j.jvca.2014.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Indexed: 11/11/2022]
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New frontiers in aortic therapy: focus on deliberate hypotension during thoracic aortic endovascular interventions. J Cardiothorac Vasc Anesth 2014; 28:843-7. [PMID: 24746338 DOI: 10.1053/j.jvca.2014.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Indexed: 11/11/2022]
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Abstract
OBJECTIVE To determine operative outcomes of right mini-thoracotomy mitral valve surgery utilizing port access technology in first-time and reoperative cardiac surgery patients. METHODS From 2002 to 2011, 881 patients underwent minimally invasive mitral valve surgery. Of these, 154 patients had previous cardiac operations via sternotomy (Group 1), of which 18 (12%) had two previous operations. Seven hundred and twenty-seven patients had no previous cardiac operations (Group 2). RESULTS Patient demographics were similar in both groups. In Group 1, 76 (49%) patients had previous coronary artery bypass grafting, 13 (8%) had previous aortic valve surgery, and 57 (37%) had previous mitral valve surgery. Preoperative echo findings for Groups 1 and 2 included severe mitral regurgitation (MR) (88%, n = 135; 94%, n = 687), mitral stenosis (MS) (4%, n = 6; 2%, n = 12), MS + MR (8%, n = 13; 4%, n = 28), and ejection fraction (48%, 56%). Operative procedures in Groups 1 and 2 were MV repair (54%, n = 84; 89%, n = 645) and MV replacement (46%, n = 70; 11%, n = 82). Circulatory management techniques for Groups 1 and 2 included endoballoon (75%, n = 116; 79%, n = 576), Chitwood clamp (8%, n = 12; 20%, n = 147), and fibrillatory arrest (17%, n = 30; 0.5%, n = 4). Perioperative outcomes were: stroke: 2.5%, 1.6%; reoperation for bleeding: 5%, 6%; valvular reoperation rate: 0.6%, 2%; aortic dissection: 2.5%, 1%; and wound infection: 0%, 0%. Transfusion requirement was 49% (n = 76) and 31% (n = 232), respectively. Median hospital stay was seven and seven days, respectively. On postoperative echocardiography, 98% (n = 151) and 99% (n = 718) of patients had zero or trace MR (1+) with 100% freedom from MR > 2+. In-hospital mortality was 3% (n = 5) and 1% (n = 8). CONCLUSIONS Operative outcomes with minimally invasive mitral valve surgery utilizing port access technology can be performed safely. Stroke rate was higher in the reoperative cases (p = NS) although similar to reports evaluating redo sternotomy in mitral valve cases.
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The utility of atrioventricular pacing via pulmonary artery catheter during transcatheter aortic valve replacement. J Cardiothorac Vasc Anesth 2014; 29:417-20. [PMID: 24462517 DOI: 10.1053/j.jvca.2013.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Indexed: 11/11/2022]
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CASE 12--2014. Inferior vena cava compression by retroperitoneal hematoma during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2014; 28:1403-9. [PMID: 24461363 DOI: 10.1053/j.jvca.2013.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Indexed: 11/11/2022]
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Con: patient-prosthesis mismatch now is not an important consideration in the majority of patients after aortic valve replacement. J Cardiothorac Vasc Anesth 2013; 28:184-188. [PMID: 24183317 DOI: 10.1053/j.jvca.2013.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Indexed: 11/11/2022]
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Validation study of Doppler-derived transmitral valve gradients compared to near simultaneously obtained directly measured catheter gradients immediately after mitral valve repair surgery. J Card Surg 2013; 28:329-35. [PMID: 23879336 DOI: 10.1111/jocs.12125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the accuracy of Doppler-derived transmitral valve gradients immediately after mitral valve repair by comparing them with near simultaneously obtained direct catheter gradients. DESIGN A prospective study. SETTING A tertiary care medical center. PARTICIPANTS Twenty elective adult surgical patients presenting for mitral valve repair surgery. METHODS Mitral valve surgery proceeded in standard fashion except for the use of a smaller than usual left ventricular vent catheter (Medtronic DLP 10 French left heart vent catheter). After completion of the mitral valve repair and subsequent cardiac de-airing, the patient was weaned from cardiopulmonary bypass. Immediately after separation, the study period began. Near simultaneous transmitral Doppler gradients were obtained with directly measured catheter gradients via the vent catheter. RESULTS While the mean peak gradient difference of 1.1 mmHg was small (p-value 0.18, 95% CI: -0.54 to 2.73 mmHg), the correlation between Doppler and catheter gradient measurements (Pearson correlation coefficient r = 0.54, p = 0.055) only approached statistical significance due to the large variance associated with the small sample size. In all patients with a peak gradient greater than 10 mmHg (4 of the 20 patients), overestimation of catheter gradients by Doppler occurred, with two showing a 62% to 73% discrepancy. In these two cases, there was also evidence for elevated left ventricular end-diastolic pressure (LVEDP) along with high transmitral blood flow velocities. CONCLUSION Doppler-derived transmitral gradients provide a simple, safe, and reliable measure of the true physiologic transmitral valve gradient. At the same time, it is important to recognize that significant Doppler over-estimation of catheter gradients may occur in patients with elevated Doppler transmitral velocities. The causes of these overestimations are unknown. They may be related to technical recording errors. They may also be related to an inherent weakness in Doppler technology--its inability to account for any distal recovery of pressure, which in a select group of patients could be significant.
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Pro: Cerebral Oximetry Should be a Routine Monitor During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:385-9. [DOI: 10.1053/j.jvca.2012.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Indexed: 12/13/2022]
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Comparison of transesophageal echocardiographic analysis and circulating biomarker expression profile in calcific aortic valve disease. THE JOURNAL OF HEART VALVE DISEASE 2013; 22:156-165. [PMID: 23798203 PMCID: PMC4118022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Aortic valve sclerosis (AVSc), the early asymptomatic stage of calcific aortic valve disease (CAVD), is characterized by a progressive thickening of the aortic cusps without obstruction of the left ventricular outflow. In spite of its high prevalence, there are no molecular markers to characterize the early stages of CAVD before it progresses to a severe, symptomatic stage of aortic valve stenosis (AVS). The study aim was to identify any correlation between circulating biomarkers and transesophageal echocardiography (TEE) evaluation. METHODS A total of 330 patients with various degrees of CAVD was enrolled into the study. Blood was collected from each patient prior to surgery, and analyzed using ELISA kits following the manufacturers' instructions. RESULTS Significantly higher plasma osteopontin (OPN) levels were observed in AVSc patients (72.7 +/- 1.8 ng/ml; p < 0.001) and AVS patients (64.3 +/- 5.1 ng/ml; p < 0.001) when compared to controls (30.3 +/- 1.8 ng/ml). Parathyroid hormone (PTH) levels in AVSc and AVS patients (164.1 +/- 16.5 and 134.3 +/- 14.6 pg/ml; p < 0.001 and p = 0.04, respectively) were also significantly higher than in controls (61.8 +/- 4.92 pg/ml). Upon further analysis, plasma levels of OPN (p < 0.001) and PTH (p < 0.001) were found to be significantly higher in asymptomatic AVSc patients, even before calcium deposition was detected on TEE evaluation. Fetuin-A levels were lower at all stages of CAVD when compared to controls (p < 0.001 and p < or = 0.05, respectively), but were comparable among the patient groups. NT-proBNP levels were significantly higher in AVS patients than in controls (p < or = 0.01). CONCLUSION Serum levels of OPN, PTH, and fetuin-A showed a significant association with different stages of CAVD, with variations in their levels occurring before calcium nodules are visualized during TEE evaluation. The study results may help not only to provide a better understanding of the progression of CAVD but also to develop new tools that can be used to stage these patients.
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CASE 3--2012. Iatrogenic circumflex artery injury during minimally invasive mitral valve surgery. J Cardiothorac Vasc Anesth 2012; 26:512-9. [PMID: 22459930 DOI: 10.1053/j.jvca.2012.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Indexed: 11/11/2022]
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Anesthetic considerations during minimally invasive mitral valve surgery. Semin Cardiothorac Vasc Anesth 2012; 16:11-24. [PMID: 22361820 DOI: 10.1177/1089253211434591] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Advances in instruments and visualization tools as well as circulatory systems for cardiopulmonary bypass during the late 1990s have stimulated widespread adoption of minimally invasive mitral valve surgery (MIMVS). Today, MIMVS is the standard approach for many surgeons and institutions. There are multiple benefits of MIMVS. Patient satisfaction and improved cosmesis are important. Additionally, studies have consistently shown faster recovery times and less associated pain with MIMVS. Statistically significant improvement in bleeding, transfusion, incidence of atrial fibrillation, and time to resumption of normal activities with MIMVS has also been shown when comparing MIMVS with conventional mitral surgery. Most important, these benefits have been achieved without sacrificing perioperative safety or durability of surgical repair. Although a steep learning curve still exists given the high level of case complexity, continued development fueled by increasing patient demand may allow for even further expansion in the use of minimal invasive techniques.
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Early Diagnosis of Superior Vena Cava Obstruction Facilitated by the Use of Cerebral Oximetry. J Cardiothorac Vasc Anesth 2011; 25:1101-3. [DOI: 10.1053/j.jvca.2010.08.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Indexed: 11/11/2022]
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Analysis of osteopontin levels for the identification of asymptomatic patients with calcific aortic valve disease. Ann Thorac Surg 2011; 93:79-86. [PMID: 22093695 DOI: 10.1016/j.athoracsur.2011.08.036] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 08/11/2011] [Accepted: 08/15/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Calcific aortic valve disease (CAVD) is the most common cause of acquired valve disease. Initial phases of CAVD include thickening of the cusps, whereas advanced stages are associated with biomineralization and reduction of the aortic valve area. These conditions are known as aortic valve sclerosis (AVSc) and aortic valve stenosis (AVS), respectively. Because of its asymptomatic presentation, little is known about the molecular determinants of AVSc. The aim of this study was to correlate plasma and tissue osteopontin (OPN) levels with echocardiographic evaluation for the identification of asymptomatic patients at risk for CAVD. In addition, our aim was to analyze the differential expression and biological function of OPN splicing variants as biomarkers of early and late stages of CAVD. METHODS From January 2010 to February 2011, 310 patients were enrolled in the study. Patients were divided into 3 groups based on transesophageal echocardiographic (TEE) evaluation: controls (56 patients), AVSc (90 patients), and AVS (164 patients). Plasma and tissue OPN levels were measured by immunohistochemical evaluation, enzyme-linked immunosorbent assay (ELISA), and real-time quantitative polymerase chain reaction (qPCR). RESULTS Patients with AVSc and AVS have higher OPN levels compared with controls. OPN levels are elevated in asymptomatic patients with AVSc with no appearance of calcification during TEE evaluation. OPN splicing variants OPN-a, OPN-b, and OPN-c are differentially expressed during CAVD progression and are able to inhibit biomineralization in a cell-based biomineralization assay. CONCLUSIONS The analysis of the differential expression of OPN splicing variants during CAVD may help in developing diagnostic and risk stratification tools to follow the progression of asymptomatic aortic valve degeneration.
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It Takes a Team: Preventing Deep Sternal Wound Infections. Am J Infect Control 2011. [DOI: 10.1016/j.ajic.2011.04.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Balloon-assisted deployment prevents endograft misalignment during hybrid aortic arch repair. Ann Thorac Surg 2011; 91:1982-4. [PMID: 21620000 DOI: 10.1016/j.athoracsur.2010.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2010] [Revised: 11/06/2010] [Accepted: 11/10/2010] [Indexed: 11/17/2022]
Abstract
Misaligned deployment refers to eccentric flaring of the bare stent portion of the endograft that causes proximal device retroflexion resulting in suboptimal graft placement. A 71-year-old woman with 6.8-cm distal aortic arch aneurysm underwent hybrid repair with combination of open aortic arch debranching and subsequent thoracic endovascular aortic repair. During endograft deployment, misaligned opening occurred; this was corrected by using a balloon-assisted graft deployment. Follow up imaging continues to demonstrate complete aneurysm exclusion. Misaligned deployment is a clinical challenge; we hereby present a previously undescribed technique to accommodate this limitation of the current endograft technology.
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Takotsubo Cardiomyopathy Associated with Cardiac Arrest Following Cardiac Surgery: New Variants of An Unusual Syndrome. J Card Surg 2010; 25:679-83. [DOI: 10.1111/j.1540-8191.2010.01135.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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The Fontan circulation and right parietal craniotomy for seizures: the challenges of adult congenital heart disease. J Clin Anesth 2010; 22:460-5. [PMID: 20868969 DOI: 10.1016/j.jclinane.2009.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 06/24/2009] [Accepted: 07/01/2009] [Indexed: 11/27/2022]
Abstract
The management of a patient who had previously undergone surgical palliation of tricuspid atresia at the age of two, and who required right parietal craniotomy for resection of seizure focus, is presented. The anesthetic considerations in patients with Fontan physiology are also presented, as well as the impact on patients undergoing neurosurgical procedures, specifically, craniotomy for seizure focus resection. The physiologic demands of modern surgical practice requires that there is a thorough understanding of the complex circulations that exist in patients with congenital heart disease.
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Reoperative Mitral Valve Surgery by the Port Access Minithoracotomy Approach Is Safe and Effective. Ann Thorac Surg 2009; 87:1426-30. [DOI: 10.1016/j.athoracsur.2009.02.060] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 02/18/2009] [Accepted: 02/20/2009] [Indexed: 10/20/2022]
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Reply. J Clin Anesth 2006. [DOI: 10.1016/j.jclinane.2006.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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How long to postpone an operation after a myocardial infarction? J Clin Anesth 2006; 18:325-7. [PMID: 16905075 DOI: 10.1016/j.jclinane.2006.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 05/03/2006] [Indexed: 10/24/2022]
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A randomized controlled clinical trial of real-time needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department. J Cardiothorac Vasc Anesth 2006; 19:310-5. [PMID: 16130056 DOI: 10.1053/j.jvca.2005.03.007] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department, to determine cumulative cannulation success by method, to determine first-pass cannulation success by method and operator, and to determine arterial puncture by method and operator. STUDY DESIGN Prospective, observational, and randomized. Blinding was not possible. Cohort size was calculated for 80% power to detect a technique difference, with significance defined as p < 0.05. SETTING Operating rooms of the Hospital of the University of Pennsylvania. PARTICIPANTS Elective surgical patients requiring internal jugular venous cannulation. INTERVENTIONS Cannulation of the internal jugular vein occurred by needle-guided ultrasound (NGU) or by ultrasound without a needle guide. MAIN RESULTS Four hundred thirty-four procedures were studied in 429 patients. NGU significantly enhances cannulation success after first (68.9%-80.9%, p = 0.0054) and second (80.0%-93.1%, p = 0.0001) needle passes. Cumulative cannulation success by the seventh needle pass is 100%, regardless of technique. The needle-guide specifically improves first-pass success in the junior operator (65.6%-79.8%, p = 0.0144). Arterial puncture averages 4.2%, regardless of technique (p > 0.05) or operator (p > 0.05). CONCLUSIONS Although the needle guide facilitates prompt cannulation with ultrasound in the novice operator, it offers no additional protection against arterial puncture. This may be because of a lack of control of needle depth rather than needle direction. A possible solution may be biplanar ultrasound for central venous cannulation.
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